Antipsoriatics, Topical

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
CALCIPOTRIENE DOVONEX CREAM (G) Y PA Document  
CALCIPOTRIENE CALCIPOTRIENE CREAM (G) Y PA Document  
CALCIPOTRIENE CALCIPOTRIENE SOLUTION Y PA Document  
CALCIPOTRIENE/BETAMETHASONE CALCIPOTRIENE-BETAMETHASONE DP OINT. (G) Y PA Document  
CALCIPOTRIENE/BETAMETHASONE TACLONEX OINT. (G) Y PA Document  
TAZAROTENE TAZAROTENE CREAM (G) Y PA Document  
TAZAROTENE TAZORAC CREAM (G) Y PA Document  
TAZAROTENE TAZORAC GEL (GRAM) Y PA Document  
CALCIPOTRIENE SORILUX FOAM N PA Document  
CALCIPOTRIENE CALCIPOTRIENE OINT. (G) N PA Document  
CALCIPOTRIENE CALCITRENE OINT. (G) N PA Document  
CALCIPOTRIENE/BETAMETHASONE ENSTILAR FOAM N PA Document  
CALCIPOTRIENE/BETAMETHASONE TACLONEX SUSPENSION N PA Document  
CALCITRIOL CALCITRIOL OINT. (G) N PA Document  
CALCITRIOL VECTICAL OINT. (G) N PA Document  
TAZAROTENE AVAGE CREAM (G) N PA Document  
COAL TAR ANTI-DANDRUFF SHAMPOO PA Document  
COAL TAR DHS TAR SHAMPOO PA Document  
COAL TAR DHS TAR GEL SHAMPOO PA Document  
COAL TAR THERA-GEL SHAMPOO PA Document